The government’s white paper on health and social care is a staging post in the development of integrated care. Its core proposals—to establish integrated care systems as statutory bodies, introduce a duty to collaborate across the health and care system, and dismantle rules on competition and procurement—build on work underway across England. Reorganisations are usually an unwelcome and unnecessary distraction, but this time around the gains should outweigh the pain of undoing the damage created by Andrew Lansley’s 2012 reforms.
Realising these gains will take more than legislation, welcome though that is in marking a decisive shift from competition to collaboration and removing some of the barriers to progress. Equally important is an investment of time and resources in building collaborative relationships which have been undermined by over thirty years of market-oriented NHS reforms. This includes recognising that organisational autonomy needs to give way to partnership working, both within the NHS, and between the NHS and other bodies.
As this happens, it is vital to remember that many of the benefits of integrated care occur when teams focus on joining up care. Examples include discharging patients through collaboration between hospitals, community health services and social care, caring for patients with mental health needs through psychiatric liaison teams in acute hospitals, and providing rapid access to specialist advice when general practices work closely with hospital colleagues. Team working across organisations and services is the building block of integrated care.
Some integrated care systems have gone further than joining up care by working differently with the people and communities they serve. This includes ensuring that the voices of patients, service users, and carers are in the room when decisions are made and using the expertise of voluntary and community sector organisations to enhance the support offered to people in need. The Healthier Wigan Partnership is a living example of what can be achieved when local authorities and their partners work together to prevent ill health and enable people to be active agents of change.
Wigan Council has made deep cuts in its spending as a result of the austerity policies of the coalition and Conservative governments. Investment in voluntary and community sector organisations has increased even as the council’s own services have been cut, underpinned by a philosophy of listening to what matters to people and working with them to find solutions. The partnership is expressed in the Wigan Deal which sets out what the council will do and what it asks of the community in return. Outcomes for local people have improved on a number of metrics.
The Achilles heel in the government’s plans is the fragility of social care, cruelly exposed during the covid-19 pandemic. In his first speech as NHS chief executive in 2014, Simon Stevens set out the case for bringing health and social care together, adding that “no-one should pretend that just combining two financially leaky buckets will magically create a watertight funding solution.” The last seven years have seen various attempts to plug the leaks, such as the Better Care Fund, but there has been an abysmal failure by successive governments to come forward with proposals for reform.
Social care matters because of the ageing population and the changing burden of disease. The challenge of chronic diseases and multimorbidity will only be met through closer integration between health and social care underpinned by a funding model that addresses the complexities and inequities of the current system. This will require substantial increases in public spending on social care and the progressive alignment of entitlements to health and social care.
Action is also urgently needed to develop a credible social care workforce strategy and value the contribution of unpaid carers. On these and other issues England would do well to take a lead from the independent review of adult social care in Scotland and its advocacy of a National Care Service based on people’s rights and capabilities.
As the review argues, priority should be given to prevention and early intervention with the aim of promoting independent living. This includes involving people who need support in the planning and design of services. In place of competition and contracting, the review emphasises the need to develop trusting relationships and cultures of collaboration, mirroring the aspirations of the English white paper.
In the 2014 Reith lectures surgeon and writer Atul Gawande argued that we live in “the century of the system” and need to design ways in which we can work together to make best use of different knowledge and skills. Integrated care systems offer one way of doing this by enabling NHS organisations, local authorities and other partners to join up care, improve population health and lead recovery from covid. Their success will depend on the ability of leaders in the public and voluntary sectors to work as system partners and the willingness of the government to reform social care.
Chris Ham is co-chair of the NHS Assembly, chair of the Coventry and Warwickshire Health and Care Partnership, and non-executive director of the Royal Free London Hospitals NHS Foundation Trust.
Competing interests: none declared.